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Up Front | Mar 2016

A Memorable Case

Once in a while, I have the opportunity to perform surgery on important and special people, be they professional athletes, family members, or close friends. The most recent example is my father, who is a practicing cataract and refractive surgeon as well as my partner.

Our discussion of the procedure lasted at least 4 years from the time he first expressed interest in having cataract surgery. The prolonged conversation revolved around timing, the type of implant, and the possible use of a femtosecond laser. Eventually, my father’s vision problems led him to book the dates of his own surgery. At that time, his BCVA was 20/20, and he was experiencing significant glare, especially when facing a window or flying his Cirrus SR22 aircraft on a sunny day. He wore +2.00 D contact lenses to correct his progressive hyperopia and always had a pair of readers around his neck.

My father has been in practice for 40 years and is an astute surgeon and clinician. My conservative side prompted me to nudge him to select a monofocal IOL with a bilateral distance target. Theoretically, this lens design and strategy posed the least risk to his extremely active lifestyle and ability to perform surgery himself. My father, however, insisted on the Crystalens (Bausch + Lomb). Together, we have implanted thousands of these IOLs. We have seen results that were amazing and others that were not, with a subsequent need for a YAG laser capsulotomy, PRK, and occasionally a second surgical intervention. Nevertheless, my father believed that this accommodating lens would give him the best chance of achieving excellent-quality distance vision and some intermediate vision without glasses, and he was very comfortable with the prospect of needing glasses to read small print. His lifestyle made a multifocal IOL completely out of the question.

My father and I have successfully performed femtosecond laser cataract surgery thousands of times, but we avoid the technology in some patients. For example, we noticed that the capsular edge is slightly more prone to contraction after the laser procedure. Perhaps the treatment causes some type of mild inflammation or stimulus that produces mild fibrosis and contraction of the anterior capsule. Maybe cortical cleanup is slightly more difficult, leaving behind more residual lens epithelial cells. Regardless, we favor a manual capsulorhexis for patients receiving a Crystalens unless the cataract is very dense and we feel the benefit of laser fragmentation outweighs the risk of anterior capsular fibrosis. Because my father’s lenses were soft and the cataracts mild, we opted not to use the laser. He had only 0.20 to 0.30 D of against-the-rule astigmatism in both eyes, which we expected to address with the corneal incision.

According to the America Medical Association, “Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered.”1 This statement reminds me why I am not a member of the organization. Plenty of ophthalmologists choose to refer family members to a trusted colleague, but many others operate on their own family members.

My father trusted me with his eyes. After 15 years of practice, I was not concerned about my surgical ability. I have operated on other family members, including my mother, and eye surgeons. They have all done well. Even so, I am relieved to have my father’s surgery behind me. Fortunately, both operations went beautifully. I performed early YAG laser capsulotomies to avoid capsular contraction and any change in refraction. Postoperatively, my father has enjoyed a return to a much higher quality of vison with a reduction in dysphotopsia and glare and an improvement in contrast sensitivity. In addition, he no longer needs to wear the contact lenses. This memorable case was a tremendous learning experience.

Robert J. Weinstock, MD
Chief Medical Editor

1. Opinion 8.19-self-treatment or treatment of immediate family members. AMA website. Issued June 1993. http://bit.ly/1PbVRCv. Accessed February 5, 2016.

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